1. The World Bank Global HIV/AIDS Program (GHAP) Global AIDS M&E Team (GAMET) Uganda Country MoT Study National Synthesis Results and Policy and Program Implications UNAIDS/World Bank – GAMET Satellite Session Know Your Epidemic, Know Your Response XVII AIS Conference, Mexico 2008 Republic of Uganda Uganda AIDS Commission

2. Acknowledgement MoT Study Team  F Wabwire-Mangen - Task 1  Martin Odiit - Task 2  Wilford Kirungi - Task 3  David Kaweesa - Task 4 Technical Steering Committee  Sam Ruteikara - NPC  Rose Nalwadda – NAC  Grace Mulindwa – NAC  John Rwomushana – NAC  Samuel Enginyu - MoH  Alex Opio - MoH  Joshua Musinguzi – MoH  Margaret Achom –CDC Uganda  Wolfgang Hladik - CDC Uganda  Nuwagira Innocent – WHO  Rosemary Kindyomunda –UNFPA Lab Director Uganda AIDS Commission/Ministry of Health UNAIDS Country Office  Malayah Harper  James Wanyama UNAIDS RST  Susan Kasedde  Mark Colvin

3. Background  HIV epidemic in Uganda, severe, heterogeneous, mature and generalized; prevalence at 6.4%  Prevention not achieving desired results: HIV is growing with new infections outstripping deaths  Care & Tx given more resources then prevention In 05/06, 53% went to Care & Tx; 31% went to prevention  Resources not aligned to evidence of need or effectiveness of interventions 32% of prevention budget went to VCT while 8% went to PMTCT and 0% to circumcision

4. Methods – Innovations and challenges Innovations  Peer consultation  Supplemented desk review with KII  Sensitivity and uncertainty analysis  Validation of resource allocation data with ADPs (planned) Challenges  No single repository for data on prevention  Data not in the form and period required  Resource data most diff to access  Choice of prevention categories

5. ‘Know your epidemic’ – Pattern of HIV  Evidence of stabilization or rise of HIV prevalence  Deterioration in behavioural indicators for men  Shift from casual single to long-term marital relationships  Shift from treatable to untreatable STIs High burden of HSV-2 at 44% Prevalence of syphilis 3%  Shift from younger to older age-groups Highest prevalence for men (9.9%) among 35 – 39 years; for women (12.1%) among 30 – 34 years 5

6. ‘Know your epidemic’ – Factors Fuelling Risk Factors for HIVDrivers of the Epidemic  Concurrent sexual partners  Discordance  Transactional sex  Cross-generational sex  Lack of condom use  Presence of HSV-2  Intact foreskin  Alcohol and drug use  Behavioural disinhibition due to ART  Socio-cultural factors incl marriage and family values  Poverty and wealth  Low status of women and girls  Human rights, Stigma and discrimination  Inequity and access to prevention, care and treatment

7. Estimates of Adult HIV incidence by Mode of Transmission- Uganda 2008 Total of 91,546 infections out of 13.1 million adult population. Majority (46%) of these infections will be as a result of MP with 22% among partners MP & 24% MP (They are 24% of the adult popn). Mutual monogamous HS account for 43% and are 46% of the adult popn.

8. Populations, Incidence and Percentage of incidence by Mode of Transmission Mode of Transmission Total number with exposure Percentage with risk behaviour Incidence % of incidence Injecting Drug Use (IDU)9940.0%2580.28 Partners IDU2520.0%100.01 Sex workers32,6520.3%8330.91 Clients189,3811.5%7,1727.83 Partners of Clients108,6760.8%1,6601.81 MSM3,9760.0%5590.61 Female partners of MSM1,5690.0%920.10 Multiple partnership (MP)1,808,91913.9%21,72223.73 Partners MP (PMP)1,417,88110.9%19,92521.76 Mutual monogamous heterosexual sex (MM)6,022,31746.1%39,26142.89 No recent risk3,474,16926.6%00.00 Medical injections13,060,787100.0%540.06 Blood transfusions134,0531.0%00.00

9. ‘Know your response’ – Programs Implemented Prevention program areas Policies or guidelines available Target PopnComments on implementation and which drivers or MoT Media and IECNoGeneral popn. Messages not standardised Not targeted to known high risk popns Behavior ChangeNoLow coverage-mainly youthNot targeting cohabiting/married CondomsYesGeneral populationTargets-non-regular partners but not cohabiting/married HCTYesGeneral populationTargets mothers but less for men PMTCTYesMothers and their babiesMTCT STIYesGeneral populationSexual transmission Blood SafetyYesRecipients of blood transfusionBlood borne Infection ControlYesMainly health workersCommunity e.g Barbers not addressed adequately PEPYesMainly health workers & in ART sitesLow coverage for rape victims and domestic violence HIV education in schools YesPrimary & Secondary schools but low coverage Special programs for tertiary institutions lacking

10. ‘Know your response’ – Programs Not Implemented HIV prevention program areas Policies or guidelines available Responding to which drivers Male circumcisionNoSexual transmission Services for MSMsNoAnal sexual transmision Services for IDUsNoIntravenous transmission FishermenNoCasual sexual transmission Truck driversNoCasual sexual transmission Uniformed servicesNoCasual sexual transmission

11. % allocation of the $249 in the National response by thematic area (2005/06)

12. % allocation of resources in by prevention intervention (2005/06)

13. Linking the response to the epidemic (‘KYE-KYR’ synthesis)  No programs or funding for MARPs  No programs or funding targeting married and co-habiting specifically  Funding not targeted to prevention with positives (PWP) but rather to ART and care  Environmental, societal and contextual factors diffusely defined with no specific policies  Funding of blood transfusion averting a lot of possible new infections

14. Recommendations  Institutionalize MoT in NAC and MoH operations  Encourage evidence-based planning & programs  Re-align prevention to most in need populations  Develop repository for strategic information on national response  Strengthen routine sources of program data  Conduct sero-behavioral surveys for MARPs  Conduct MoTs regularly after every AIS

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